A place to share new approaches to Neglected Tropical Diseases

Month: September 2015

This month COUNTDOWN has been awarded additional funding of £1M from the Research and Evidence Division within Department for International Development (DFID), UK. The expanded COUNTDOWN partnership allows implementation research to be undertaken within Nigeria, in Kaduna and Ogun States. By supporting and strengthening the activities of The Federal Ministry of Health and Sightsavers, COUNTDOWN will address several context-specific issues within neglected tropical disease (NTD) control. In so doing, this will foster the scale-up and sustainability of current and future interventions, encouraging a broader inter-sectoral dialogue within the health system.

Set up in December 2014 following an initial £7 million grant allocation from DFID, COUNTDOWN will trial and evaluate new approaches to drug distribution, which target those who are currently overlooked and excluded, examining how NTD programmes can be better integrated into broader health system responses. As a push towards universal access to health services, COUNTDOWN is working to support the achievement of the 2020 targets set out in the London Declaration on NTDs.

LSTM’s Professor Russell Stothard, COUNTDOWN Director, commented “Inclusion of Nigeria into the COUNTDOWN partnership is a key step within our research programme. We aim to ensure that our research leaves a lasting legacy in Nigeria, paving a way for increased domestic funding which ultimately increases the scale and scope of NTD control. Helping Nigeria reach the WHO 2020 targets is a major driving force in our work. I sincerely hope it will lead to a tangible benefit and improvement in the health of those populations in West and Central Africa vulnerable to NTDs”.

Each of us touches one place
and understands the whole that way.
The palm and the fingers feeling in the dark
are how the senses explore the reality of the elephant.

To me this illustrates the importance of multidisciplinary approaches – different disciplines illuminate different aspects or bring new ways of seeing or addressing an issue or problem. The complexity and challenges posed by addressing Neglected Tropical Diseases (NTDs) requires multidisciplinary approaches and these are at the heart of COUNTDOWN. Recent COUNTDOWN blogs on the hotspot conundrum have highlighted the importance of applying different disciplines and methods for action here. There is also need to understand context – what works in one place may not work in another – and this too requires different methods and disciplines.

In the Liverpool School of Tropical Medicine, partnerships between parasitology and social science are relatively recent and have been strengthened through the COUNTDOWN consortium. I was fascinated to understand that the Department of Microbiology and Parasitology at the University of Buea has been partnering and fostering links with social scientists for many years. So being a good nosey social scientist I interviewed Prof. Samuel Wandji to understand more … Samuel explained links with social scientists go back to a Tropical Disease Research (TDR) funded project in 2000 on the indicators for Loa loa that required both parasitological and clinical indicators. The clinical indicators required questions about the history of disease, swelling of hands, movement of the worm in the eye and length of time the worm stayed in the person’s eye. These were very difficult questions to discuss and there was need to ensure the concepts and ideas from the interviewer matched those of the interviewee and social scientists were brought in to conduct the interviews. The same methodological approach was also replicated in the Democratic Republic of Congo, with Samuel Wandji playing a key role and again working with social scientists in DRC to collect and analyse data on patient and community experience of Loa loa. In the same spirit of using multidisciplinary approach for health interventions, Samuel and his team partnered on a multi-county project (five African countries) again funded by TDR on community approaches and collaboration with community based drug distributors and community health workers for onchocerciasis, bed nets, malaria, vitamin A and directly observed treatment for tuberculosis. This more complex health intervention required both multidisciplinary partnerships, participatory approaches and ongoing community engagement.

Samuel explained that it was important to engage the entire community throughout the process and that community ownership and support of community based workers was critical to their success and sustainability.

In the Buea’s Department of Microbiology and Parasitology there are now five social scientists, three of whom work on COUNTDOWN and they are part of the “community of life” in the department. Samuel and the department are committed to the sustainability of multi-disciplinary research and students are supported and nurtured in a range of approaches. Samuel explained that he sees himself as a public health parasitologist, and that part of the challenge is understanding how the parasite lives within an organism and sustains itself – this is a complex ecosystem that requires different approaches to understand it. Samuel said “if the question or problem we need to address is not relevant to the community we can’t start the work – we need to be able to have an impact on communities, and this requires partnership with social science at the beginning, throughout and at the end”.

The whole is truly bigger than the sum of the parts accessible to any one health system discipline. In COUNTDOWN we are lucky to partner with Buea’s Department of Microbiology and Parasitology who have strengths and experience in driving forward multidisciplinary research for action for NTDs.

Read more about the work of Buea’s Department of Microbiology and Parasitology

We recently completed the first social science meeting in Cameroon for COUNTDOWN where colleagues from The University of Buea, The University of Yaoundé and Liverpool School of Tropical Medicine came together to develop collaborative social science research protocols for COUNTDOWN. So what?

Using methods from social science generates important data that has the potential to reduce the prevalence of Neglected Tropical Diseases (NTDs) in Cameroon; data which cannot be captured from the biomedical sciences. However social science methods are often overlooked when addressing NTDs, or even sneered at. Many ‘pure’ scientists cannot understand the value of conducting social science or what impact this academic discipline has in addressing these so called “diseases of poverty”. So what?

So this is one of the challenges we face when working on a multidisciplinary programme that involves social science, parasitology, entomology, and vector biology. To combat this challenge we have come up with key research questions addressing each level of the health system in Cameroon, of which there are five: national, regional, district, health area and community. These research questions can be grouped across five core areas which are critical to a holistic approach to NTDs. These are:

Funding, governance and donor priorities;

Health system integration and disease programme co-implementation;

Partnerships and multi-sectoral working beyond the health sector;

Community drug distributors; and

Gender, disability, equity and NTDs.

So what does this mean in practice?

At the national level through key informant interviews and stakeholder workshops, linked to the research area of funding, governance and donor priorities, we will explore how donor priorities influence the way programmes are managed. In addition, we will assess how decisions made internationally support or challenge country priorities and processes for NTD control and elimination.

At the regional and district level through key informant interviews, stakeholder workshops, focus group discussions, direct observation and document review, linked to the research area of health systems integration and co-implementation, we will seek to understand how current platforms for NTD co-ordination are functioning and promoting co-implementation of disease programmes.

At the district level through key informant interviews, stakeholder workshops, focus group discussions, and direct observation, linked to the research area of partnerships and multi-sectoral working, we will identify what multi-sectoral partnerships are in place and what opportunities are missed.

At the health area level through participatory methods such as ‘photo-voice’, linked to the research area of community drug distributors, we will identify how community drug distributors are currently supported and co-ordinated by and within the health system. We will explore how their role within communities can promote community ownership of the philosophy of eliminating NTDs.

At the community level using anthropological methods such as ethnographic journals, linked to the research area of gender, disability equity and NTDs, we will seek to understand how communities perceive and talk about NTDs and how we can be more responsive to their understandings, particularly in the way we generate health education messaging. We will consider the needs of individuals currently ‘invisible’ to existing NTD programmes, such as out of school children, people living with disability and pregnant women. We will assess how stigma and disability present barriers in accessing treatment for NTDs.

The collaborative nature of social science within COUNTDOWN is not limited to work in Cameroon. Our work in Ghana takes a similar approach and the same is likely to be true in Liberia and Nigeria. So what?

Well, this allows for learning between these diverse African contexts who are in differing phases of disease control to address bottlenecks and implementation dilemmas to accelerate the elimination of NTDs. So what?

Social science may have a long way to go to prove its worth in the field of NTDs, but we believe that without it, elimination and eradication of diseases propagated by social processes is impossible. The medicines, the public health strategies are there. So what?

Control and elimination cannot succeed without the understanding and the explanation of the social process, social organisations, beliefs and perception of societies that are the principal actors and people affected by NTDs.

In preparation for our stakeholder meeting in Liberia detailed in our previous blog I spent some time interviewing Haja Wurie. Haja is based at the College of Medicine and Allied Health Sciences in Sierra Leone and works as part of the ReBUILD Consortium focusing on health systems research in post-conflict countries. Interviewing Haja, allowed time for reflection on the impact Ebola has had in Sierra Leone and enabled us to begin to strategize how best to move forward to build back more ‘responsive and resilient’ health systems. The interview will be used at our stakeholder meeting in Liberia to spark debate and encourage cross-country lesson learning.

The impact of Ebola in Sierra Leone

Haja believes that Ebola has exposed weaknesses across all pillars of the health system from service delivery to human resources for health and beyond. Haja describes the health workforce as ‘victims’ both during the conflict in Sierra Leone and during the Ebola crisis. During conflict health workers were targets of kidnap, and during Ebola they have become targets of a virus which they were ill-equipped to avoid due to lack of training and resources, at the onset of the outbreak. Ebola has impacted on health programmes through a decrease in service use because of mistrust and fear between service users and providers. Where vertical programmes, such as the Neglected Tropical Disease programme, had begun to establish themselves, Ebola has resulted in them taking ‘three steps back’. Haja believes there is ‘no more time for excuses’ and we need to address the systemic problems that allowed such a crisis to develop. There is a need for the health system to be prepared as future outbreaks of Ebola are likely once one has already occurred.

Building back better: What’s next for Sierra Leone’s health system?

Haja believes that we have to look toward strengthening all six pillars of the health system simultaneously to be able to build back better. It is too simplistic to argue for better training of staff or more available equipment without looking at all underlying factors that caused weaknesses in the system. For example, instigating infection prevention and control training is unlikely to be effective when most health workers are in facilities where there is no running water or electricity. Just as it is unproductive to have numerous donors and NGOs operating in an uncoordinated manner. So we need to think about how we strengthen systems in a holistic and unified way at a pace where no building blocks are left behind. This can be a hard thing to swallow as an academic with your own personal research interests in a specific disease area, or as the implementer of a vertical programme only concerned with a particular disease. The reality however is that unless we all start to think about the health system as a whole we are unlikely to be able to respond in a resilient manner to crisis.

What does building back better really look like?

Rebuilding trust between the health system and the communities which it is designed to serve is a critical first step in moving forward from Ebola. Haja believes that health education and health promotion are a crucial and that close-to-community providers play an essential role in their delivery. The Ebola crisis meant that there were travel restrictions within affected countries, as a result close-to-community providers had to be selected from within communities to ensure that health services did not cease altogether. Haja believes that it is these very close-to-community providers that present an opportunity for rebuilding trust. As ‘sons of soil’, they are trusted by their communities and the messages they share are respected. Driven by willingness and pride, often supported by minimal incentives (~three dollars every three months for community health workers), it is critical that community health workers are well supported by the health system they are serving.

Vertical disease programmes, such as those for the control of neglected tropical disease are essential health services. However strengthening them in isolation from the rest of the system is unlikely to contribute to a stronger health system. Through the delivery of essential health services vertical health programmes present a potential platform to strengthen another elements of health care. These health programmes should therefore look at ways to support and strengthen human resources for health through the cadre of community health workers and integrate this within their programmes. Vertical programmes could then promote co-ordination between strengthening building blocks and avoid contributing to fragmentation.

Internationally there is the scope for learning between all Ebola affected countries, specifically, Liberia, Guinea and Sierra Leone. Haja believes in the recent crisis, opportunities were missed to learn from systems in place in Uganda and this should not continue in rebuilding the health system. Countries have the opportunity to share their post-crisis action plans and ideas regarding their implementation. National ownership of health system strengthening is critical however, and it is essential that countries are given the opportunity to work together to harness donors to provide strategic support that is in line with nationally identified action plans building on countries strengths and developing their weaknesses.

Finally, Haja believes that health systems research is critical, but it has to be context relevant and led from within. There needs to be national ownership of research that incorporates community (service users and service providers) voices. Health systems research needs to be co-ordinated and directed in collaboration between policy makers, academics and health staff to ensure successful policy generation and implementation. It should not only focus on issues directly related to Ebola but explore issues across all sectors and all levels of the health system.

As I embark on a new area of research in an Ebola affected country, I will continue to ask myself; how can our research contribute to a stronger health system so that we build back better?

We must appreciate the heterogeneities of NTDs across communities and understand the factors that have resulted in persistent disease, only then can we apply a sustainable strategy for elimination.

Lymphatic Filariasis in Ghana

Lymphatic Filariasis (LF) is a mosquito-borne infection caused by filarial worms that can result in significant illness, disability and disfigurement. The LF Elimination Programme in Ghana has achieved great success with annual, community-wide distribution of microfilaricides. It is recommended that the drugs are distributed to the entire community for 5-7 years which is the estimated life span of adult worms. Mass drug administration (MDA) has been underway for over ten years, but there are still communities endemic for LF. So what is unique about these communities? Why has the recommended strategy failed to eliminate LF? Will scaling up MDA provide the final push towards elimination?

Hotspots and heterogeneities

These communities are often referred to as ‘hotspots’ and they are likely a product of the heterogeneous nature of vector-borne diseases. For example, there is great diversity among the vectors of LF ranging from those that are highly competent to incompetent, those that bite indoors and those that bite outdoors, those that preferentially feed on humans and those that are generalist feeders. There may be differences in village characteristics that can support a larger population of the most capable vectors. There may be greater risks to certain individuals of a community depending on their habits, house structure, house location and their occupation. There will be individuals in a community who decline treatment, are unavailable during distributions or prefer not to use a bed net. There may be other barriers to delivery of services and interventions. There may be differences in insecticide resistance or drug resistance influencing the efficacy of MDA and vector control.

It may not be enough to scale up access to MDA, we need to understand the dynamics that have contributed to persistent transmission in these communities in order to inform the most appropriate delivery of interventions.

Planning for change

I recently met with COUNTDOWN colleagues Dr. Benjamin Marfo, Dr. Nana Kwadwo-Britwum and Dr. Margaret Gyapong from Ghana Health Service and Dr. Mike Osei-Atweneboana from the Council for Scientific and Industrial Research, to lay the groundwork for our investigation of lymphatic filariasis hotspots in Ghana. We are planning an in-depth investigation into the social, entomological and epidemiological factors that are driving transmission. We will evaluate current epidemiology in the context of baseline prevalence. We will explore adherence to MDA, bed net usage, transmission, vector behaviours, vector competence, insecticide and drug resistance, community beliefs and practices, experiences of the health workers and drug distributors. This understanding will then inform a new approach to integrated delivery of vector control and MDA. Our study will evaluate the costs, experiences and the impacts of integrated complementary strategies for LF.

We are now making plans for our first visits to study communities in January 2016. I am particularly looking forward to joining postdoctoral researcher, Dr. Kingsley Badu for our mosquito surveys to evaluate vector behaviours and current transmission dynamics.

Margaret will speak in a satellite session on co-infections and their impact on Neglected Tropical Diseases. Panellists in this session will talk about female genital schistosomiasis and health systems, the association of the schistosome infection with inflammatory response profiles and the challenges of co-infections, in particular Visceral Leishmaniasis (VL) and HIV.

If you are going to the conference do pop along and give Margaret your support. The satellite is on Monday 7 September from 12:15 to 13:15 in the Sydney Meeting Room.